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1 Getting the best result from Opioid medicine in the management of chronic pain

2 Your doctor has prescribed you opioid medicine to help you manage your chronic pain. This patient information leaflet gives you some information about the effects of this type of medicine, and outlines what your doctor expects of you and what you can expect from your doctor when opioid pain relief is prescribed for you. What are Opioids? Opioids are a type of strong pain relieving medicine (like morphine) which can be prescribed as tablets, syrup or skin patches. Commonly prescribed opioids in Australia are: Morphine (MS Contin, Kapanol), Fentanyl (Durogesic), Oxycodone (Oxycontin, Oxynorm) Methadone, Tramadol (Tramal) and Buprenorphine (Norspan, Temgesic). While some types of pain respond well to these drugs (e.g. cancer pain), they are not as effective in most chronic pain conditions. Most research shows limited benefits, in particular with long-term treatment. Patients taking these drugs need to understand that their pain may not respond to opioids, that initial relief may not be maintained and that the side effects of this type of drug need to be carefully balanced against the benefits.

3 Why do I need a trial of this medication? Usually you need to take the drugs for a trial of about 4 weeks before you and your doctor will know if they are going to be helpful. The aim of this trial is to improve your level of functioning so that you can become more active at home, at work, and in your time off. If the trial demonstrates that you cannot achieve these goals, then long-term opioid medication will not be useful to you and the treatment will need to be discontinued. It is important to remember that taking medicines to reduce your pain is only one part of managing your pain. Being involved in normal daily activities, and participating in programs that help improve your social, physical, or psychological functioning, will be more important than if you just take a tablet; however opioids may help you to achieve these goals, if they provide pain relief. Are there any side effects? Taking opioids for pain relief is a serious step, because this type of treatment does have some risks. Some of the potential side effects are: Confusion, fuzzy thinking, poor coordination. Increased sleepiness especially if taken with other drugs or alcohol. Constipation, itching, sweating, feeling sick, vomiting and poor appetite. Physical dependence; stopping the drug suddenly will cause a withdrawal reaction. Tolerance, which means you need more and more of the drug to get the same effect. Addiction, which means you lose control of when and why you are taking the drug.

4 Most people DO NOT have any serious problems. Some of these side effects are minor and are a problem only in the first few days that the drug is taken. Others, such as constipation, may persist but can be treated. You must discuss any side effects you experience with your doctor. Some patients who are on high doses of opioid medicine for long periods of time may actually experience an increased sensitivity to pain. This condition (called opioid induced hyperalgesia) can occur because your body is not designed to have substances like morphine permanently in your blood stream this disturbs the body s own pain relief system which begins to produce pain stimulating chemicals in order to maintain a balance. If this happens, your doctor will need to decrease your dosage or change the type of your medication. Women should take precautions to prevent pregnancy while on this treatment. Those wishing to become pregnant should discuss their situation with their doctor because of the effects of opioids on unborn children. You should not drive, operate machinery, or participate in any other possibly dangerous activities while your dose is being adjusted or if you feel dizzy or drowsy. Apart from your close family and your doctor(s), don t tell people you are taking these drugs. This is for your own protection against theft and robbery. Storage of your medicine You must keep your medicine where children cannot reach it, preferably in a locked cupboard, but always up high and out of reach. Do not leave it in the bathroom or near a sink. Store medicines out of direct sunlight in a cool, dry place. Keep your medication in its original packaging until it is time to take it. Speak with your pharmacist or read the patient information leaflet that came with the medicine to check if there are any special storage requirements for your medicine.

5 Care Plan for the use of opioids (morphine-like painkillers) for the management of chronic pain Patient Name: Address: D.O.B. / / I, understand that opioid painkillers are being prescribed to me in an attempt to improve my level of functioning and reduce my pain intensity. My medical practitioner and I agree to the following conditions regarding my treatment and the prescribing of opioid medications for my pain. We have discussed that strong opioid (morphine-like) painkillers may be only partially helpful in achieving this goal and on occasion will not help at all. I understand that painkillers are only one part of the management of my chronic pain. 1. My medical practitioner is responsible for prescribing a safe and effective dose of opioids. I will only take the opioid at the dose prescribed and I will discuss any changes in my dose with my medical practitioner. 2. I am responsible for the security of my opioid medicine. Lost, misplaced or stolen prescriptions or medicine will not be replaced. 3. I will only obtain opioid medications from the medical practitioner who signs this contract, or other doctors in the same practice authorised to prescribe to me. I understand that no early prescriptions will be provided. continued over page

6 Care Plan continued continued from previous page 4. Whilst most people do not have any serious problems with this type of medicine when used as directed, there can be side effects. My medical practitioner has explained what these are and I will tell him or her if I experience them. 5. I am aware that my medical practitioner is required to notify Queensland Health if my prescription exceeds or is likely to exceed 8 weeks. 6. I agree to tell my medical practitioner if I have ever been dependent on alcohol or drugs, or if I have ever been involved in illegal activity related to any drugs including prescription medicines. I am aware that providing my medicine to other people is illegal and could be dangerous to them. 7. My medical practitioner respects my right to participate in decisions about my pain management and will explain the risks, benefits and side effects of any treatment. 8. My medical practitioner and I will work together to improve my level of function and reduce my pain. 9. I understand that my medical practitioner may stop prescribing opioids or change the treatment plan if my level of function has not improved or I do not show a significant reduction in pain intensity, or if I fail to comply with any of the conditions listed above. Patient Signature: Name: Date: Medical Practitioner: Date:

7 Why do I need to sign a care plan? Both you and your doctor are subject to strict regulations when this type of drug is prescribed. Your doctor needs to notify Queensland Health when continuing to prescribe opioid painkillers to you for longer than 8 weeks. A care plan is used so that your doctor is sure that you understand what is expected from you whilst you take this medication, and that you consent to the requirements described in the care plan. There needs to be trust, honesty and good communication between you and your doctor for these drugs to be prescribed. The doctor that prescribes you these drugs is expected to: Do their best to prescribe opioid medication safely and effectively. To arrange your appointments and prescriptions so that you do not run out of medication. In order to receive these drugs it is normal to sign a care plan with your doctor. This will list some important conditions you will need to accept. Some of the things expected of you are: Agree to get all your prescriptions for opioids from one doctor only. You should fill all your prescriptions at the same pharmacy. Agree to take the medication only as prescribed for pain relief and not to change the dosage. Medication of this type that is lost, stolen or misplaced can not be replaced. No additional prescriptions can be given to top you up if you have used all of your pain killers before your next prescription is due. If travelling away from home for long enough to need to get the drugs from a different pharmacy, you will discuss this in advance with your doctor. If you have ever been dependent on alcohol or other drugs (including prescription medicine) you need to tell your doctor before signing the care plan. A past problem of this nature does not mean that you cannot have opioids for pain relief, however it does mean that you could be at risk of developing another drug problem and your doctor needs to know this.

8 If your doctor decides that you need to stop taking these drugs, you must be careful to follow their directions about gradually stopping the drug by reducing your dose. Your doctor may stop the drug for reasons such as: You develop side effects that the doctor thinks are significant. You become less active because of the side effects of the drugs. You break the terms of the care plan you have signed. Produced by the Drugs of Dependence Unit (Reproduced with permission from the Drug and Alcohol Office, Western Australia)

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